Lessee Designation
PS2019-12 (07/17)
A. Vehicle Information (PRINT OR TYPE)
Year
Vehicle Identification Number
X
Signature of Authorized Agent
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
445 Minnesota Street
St. Paul, MN 55101-5160
Print this completed form. This form can be mailed or submitted in person to any motor vehicle Deputy Registrar office, or to
Driver and Vehicle Services, 445 Minnesota Street, St. Paul, Minnesota 55101-5160. For office locations, call 651-297-2005.
• This form records the person or group leasing a motor vehicle from a designated company (lessor). It must be signed
by the lessor's authorized agent.
• A filing fee is due when submitting a lessee designation. To determine the amount due, visit dvs.dps.mn.gov and
select Fees, or call 651-297-2126.
Make Model Type Plate Number
B. Lessee Information (PRINT OR TYPE)
Lessee's Name (LAST, FIRST, MIDDLE NAME) Date of Birth (MM/DD/YY)
Date of Birth (MM/DD/YY)Lessee's Name (LAST, FIRST, MIDDLE NAME)
D. Leasing Company (Lessor) Information (PRINT OR TYPE)
Street Address City / State / Zip code County
Name of Leasing Company (Lessor)
Date (MM/DD/YY)
NOTICE: All data collected on a motor vehicle application is required by law. Failure to provide this required data may result in
the denial of ownership transfer, vehicle registration, or other requested action. With the exception of sales tax data, lessee
information is classified as private. Only the subject of the data and those specifically authorized by law are entitled to view the
data.
Driver's License Number
Driver's License Number
C. Lessee Removal - if applicable (PRINT OR TYPE)
Date of Birth (MM/DD/YY)Lessee's Name (LAST, FIRST, MIDDLE NAME)
